Drivers of malnutrition among late adolescent and young women in rural Pakistan: a cross-sectional assessment of the MaPPS trial.

OBJECTIVE: This study aimed to characterise the burden of malnutrition and assess how underlying determinants at the structural and intermediary levels contributed to malnutrition among late adolescent and young women in rural Pakistan. DESIGN: Cross-sectional enrolment data assessment. SETTING AND PARTICIPANTS: This study was conducted using data from adolescent and young women (n=25 447) enrolled in the Matiari emPowerment and Preconception Supplementation Trial, collected from June 2017 to July 2018 in Matiari District, Pakistan. The WHO-based cut-offs were applied to anthropometric measures to estimate body mass index (BMI) categories (underweight, overweight, obese) and stunting. Hierarchical models were generated to evaluate the association between the determinants with BMI categories and stunting among late adolescent girls and young women, respectively. PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcomes of interest were BMI categories and stunting. Explanatory variables included measures of socioeconomic status, education, occupation, health, well-being, food security, empowerment and food practices. RESULTS: Regardless of age group, the prevalence of underweight was high (36.9%; 95% CI 36.3% to 37.5%). More late adolescent girls were underweight, while more young women were overweight/obese (p<0.001). Stunting affected 9.2% (95% CI 8.9% to 9.6%) of participants, of which 35.7% were additionally underweight and 7.3% overweight/obese. Compared with those in the normal weight category, those underweight were more likely to be impoverished and less empowered. Those overweight/obese were more likely to be from a higher wealth quintile and food secure. Increased education level and food security were associated with reductions stunting risk. CONCLUSIONS: This study informs the data gap and need for comprehensive research on adolescent nutritional status. Findings suggest factors related to poverty played an important, underlying role in undernutrition among participants. Commitment to improving the nutritional status of all adolescent and young women in Pakistan will be critical given the observed burden of malnutrition. TRIAL REGISTRATION NUMBER: NCT03287882.

Characterizing Retail Food Environments in Peri-Urban Pakistan during the COVID-19 Pandemic.

(1) Background: To date, there are limited data in low- and middle-income countries (LMICs) that collect, monitor, and evaluate food environments in standardized ways. The development of a pilot survey tool, tailored to LMICs and focused on retail food environments, is necessary for improving public health nutrition. (2) Methods: A novel survey tool was developed and piloted in a sample of village retail food environments (n = 224) in Matiari, Pakistan between October 2020 to April 2021. Villages were randomly selected, and food outlets were surveyed within a 500-m radius from each village center. Descriptive statistics (counts and percentages) were used to describe the characteristics of food outlets and the availability of food. To test whether there was a difference in characteristics or in the mean of number of healthy, unhealthy, and total food items available by village size, a χ2 test or one-way ANOVA was conducted, respectively. (3) Results: In total, 1484 food outlets were surveyed for food accessibility, availability, and promotion across small (n = 54), medium (n = 112), and large villages (n = 58). In small and medium-sized villages, mobile food vendors were the predominant food outlet type (47.8% and 45.1%, respectively), whereas in large villages, corner stores (36%) were more prominent. The mean number of total food items (p < 0.006) and unhealthy food items (p < 0.001) available in food outlets differed by village size. The proportion of food outlets with available fruits, meat and poultry, water, and sugar-sweetened beverages also differed by village size (p < 0.001). (4) Conclusions: This study informs the global evidence gap in the current understanding of food environments in various ethnically diverse and dynamic LMICs, and the developed methodology will be useful to other LMICs for measuring and monitoring the food environment, especially among vulnerable population groups. This work complements current national and provincial survey efforts in Pakistan.

Practices and predictors of menstrual hygiene management material use among adolescent and young women in rural Pakistan: A cross-sectional assessment.

Background: In low- and middle-income countries (LMICs), women often use inappropriate materials to manage menstruation, which can threaten their health. Improper practices can also have critical downstream consequences beyond physiologic health, including restricting adolescent girls' access to academic pursuits. Methods: We used cross-sectional data collected through a structured questionnaire from the menstruating adolescents and young women 15-23 years of age living in rural Pakistan (n = 25 305). We aimed to describe menstrual hygiene management (MHM) practices and generate a predictive model of the socioeconomic and demographic factors related to the use of MHM materials. Beliefs and barriers around MHM were also summarized. The outcome variable included: those who practiced appropriate and inappropriate MHM practices. Logistic regression was used to generate the predictive model, with results presented as odds ratios (OR) and 95% confidence interval (CI). Results: Inappropriate MHM practices were reported by 75% (n = 19 006) of participants. The majority 61.9% (n = 15 667) reported using old cloths, 12.6% (n = 3191) used nothing, and 0.5% (n = 136) used old cloth with a sanitary pad. One-fourth of participants reported appropriate MHM material use, including 16.2% (n = 4087) sanitary pads, 8.6% (n = 2167) new cloth, and a few reported using sanitary pads with new cloth 0.2% (n = 45). Inappropriate MHM practices were more common in lowest wealth quintile (OR = 4.41; 95% CI = 2.77-7.01, P < 0.0001), followed by those with no education (OR = 3.9; 95% CI = 3.36-4.52, P < 0.0001). Conclusions: The study indicates the need for multi-sectoral efforts to introduce MHM-specific and MHM-sensitive interventions to improve MHM practices, ranging from the availability of low-cost MHM materials to the inclusion of MHM education in school curriculums and within the community platforms.

Dietary diversity and social determinants of nutrition among late adolescent girls in rural Pakistan.

The conditions in which adolescent girls mature shape their health, development and nutrition. Nutrient requirements increase to support growth during adolescence, but gaps between consumption and requirements exist in low- and middle-income countries. We aimed to identify and quantify the relationship between dietary intake and diverse social determinants of nutrition (SDN) among a subset of adolescent girls 15-18.9 years (n = 390) enrolled within the Matiari emPowerment and Preconception Supplementation (MaPPS) Trial. The primary outcome, dietary diversity score (DDS), was derived by applying the Minimum Dietary Diversity for Women 10-item scale to 24-h dietary recall data collected three times per participant. To examine the associations between the SDN-related explanatory variables and DDS, we generated a hierarchical, causal model using mixed effects linear regression to account for the cluster-randomized trial design. Using all data, diets lacked diversity (DDS mean ± SD: 3.35 ± 1.03 [range: 1-7; n = 1170]), and the minimum cut-off for dietary diversity was infrequently achieved (13.5%; 95% CI: 11.6-15.6%). Consumption of starches was reported in all recalls, but micronutrient-rich food consumption was less common. Of the SDN considered, wealth quintile had the strongest association with DDS (P < 0.0001). The diets of the sampled Pakistani adolescent girls were insufficient to meet micronutrient requirements. Poverty was the most important predictor of a diet lacking in diversity, indicating limited purchasing power or access to nutritious foods. Dietary diversification and nutrition education strategies alone are unlikely to lead to improved diets without steps to tackle this barrier, for example, through fortification of staple foods and provision of supplements.

Psychometric properties of the Sindhi version of the Mood and Feelings Questionnaire (MFQ) in a sample of early adolescents living in rural Pakistan.

There is a need for reliable and valid screening tools that assess depressive symptoms in adolescents in Pakistan. To address this need, the present study examined the psychometric properties and factor structure of a Sindhi-translated and adapted version of the child-report Mood and Feelings Questionnaire (MFQ-C) and the Short Mood and Feelings Questionnaire (SMFQ-C) in a community sample of adolescents living in Matiari, Pakistan. Questionnaires were translated into Sindhi and administered by study psychologists to 1350 participants (52.3% female) 9.0 to 15.9 years old. Measurement structure was examined using confirmatory factor analysis. Internal consistency was estimated, and convergent and divergent validity were explored using subscales from the Strengths and Difficulties Questionnaire and the Screen for Child Anxiety Related Emotional Disorders. The unidimensional structure of the MFQ-C was found to be adequate, but a four-factor structure comprising core mood, vegetative, cognitive and agitated distress symptoms best fit the data (CFI = 0.97, TLI = 0.97, RMSEA = 0.05). The original unidimensional structure of the SMFQ-C was supported (CFI = 0.97, TLI = 0.96, RMSEA = 0.07). The MFQ-C and the SMFQ-C respectively showed excellent (α = 0.92) and good internal consistency (α = 0.87) as well as satisfactory construct validity with some differences observed across the MFQ-C subscales. The SMFQ-C and the adapted MFQ-C appear to be reliable and valid measures of depressive symptoms among early adolescents living in rural Pakistan. Both total and subscale scores can be derived from the MFQ-C to assess general and specific dimensions of depressive symptoms in this population.

Age-Based Anthropometric Cutoffs Provide Inconsistent Estimates of Undernutrition: Findings from a Cross-Sectional Assessment of Late-Adolescent and Young Women in Rural Pakistan.

Ambiguity around age ranges for adolescence and adulthood can make the application of age-based nutrition cutoffs confusing. We examined how estimates generated using the age-based anthropometric cutoffs for adolescent girls (10 to <19 y) and women of reproductive age (15-49 y) compared between late-adolescent and young women, and determined how application of both cutoffs affected late-adolescents' estimates. Using cross-sectional data from participants aged 15-23 y in the Pakistan-based Matiari emPowerment and Preconception Supplementation (MaPPS) Trial (n = 25,447), notably large differences in estimates were observed for stunting (30.5% and 7.9% for late-adolescent and young women, respectively; P < 0.001) and thinness (9.3% and 30.8%, respectively; P < 0.001). When both cutoffs were applied to adolescents' data, estimate differences were maintained. With each year of age, the difference for stunting increased and thinness decreased. Given the discrepancies observed both between and within groups, clarity around application of anthropometric cutoffs for youth (aged 15-24 y) is needed. This trial was registered at clinicaltrials.gov as NCT03287882.

Characterizing Micronutrient Status and Risk Factors among Late Adolescent and Young Women in Rural Pakistan: A Cross-Sectional Assessment of the MaPPS Trial.

Nutritional deficiencies are a leading underlying risk factor contributing to the global burden of disease. In Pakistan, late adolescence is considered a nutritionally vulnerable period, as micronutrient requirements are increased to support maturation, and dietary staples are nutrient poor. However, there has been limited evaluation of micronutrient status beyond anemia and its determinants. Using cross-sectional data from late adolescent and young women (15-23 years) at enrolment in the Matiari emPowerment and Preconception Supplementation (MaPPS) Trial, we aimed to describe the prevalence of key micronutrient deficiencies of public health concern, and generate hierarchical models to examine associations with proxies for social determinants of health (SDoH). The prevalence of micronutrient deficiencies was high: 53.6% (95% confidence interval (CI): 53.0-54.3%) had anemia; 38.0% (95% CI: 36.4-39.6%) iron deficiency anemia; 31.8% (95% CI: 30.2-33.3%) vitamin A deficiency; and 81.1% (95% CI: 79.8-82.4%) vitamin D deficiency. At least one deficiency was experienced by 91.0% (95% CI: 90.1-92.0%). Few SDoH were maintained in the final hierarchical models, although those maintained were often related to socioeconomic status (e.g., education, occupation). To improve the micronutrient status of late adolescent and young women in Pakistan, a direct micronutrient intervention is warranted, and should be paired with broader poverty alleviation methods.

The relationship between pubertal timing and under-nutrition in rural Pakistan.

INTRODUCTION: Sexual development in females and males are routinely measured according to the Tanner Stages. Sparse data exist on the timing of pubertal milestones in Pakistan. To fill this gap, the age of attainment of pubertal milestones and their relationship with nutritional status was explored among children and adolescents living in the rural district of Matiari, Pakistan. METHODS: Anthropometry, nutrition biomarkers and Tanner Stage were assessed among girls aged 9.0-14.9 years (n = 723) and boys aged 10.0-15.9 years (n = 662) who were free from known disease in the rural District of Matiari, Pakistan. Median age was calculated for all Tanner Stages and menarche. Multivariable linear regressions were undertaken to determine covariates associated with the timing (age) of pubertal milestones. RESULTS: Among participants living in this rural community, the median age of puberty onset for girls was 11.9 years (95%CI:10.9; 12.5) and boys was 12.3 years (95%CI:11.5; 12.9). Age at first menarche was 12.9 years (95%CI:12.1; 13.3). Undernutrition was widespread among adolescents in this community. Thirty-seven percent of females and 27.0% of males were stunted while 20.5% of females and 31.3% of males were thin. Only 8% (n = 58) of females and 12% (n = 78) of males were free from any nutrient deficiency with most adolescents having two or three nutrient deficiencies. CONCLUSIONS: Undernutrition (stunting or thinness) was associated with relatively older ages for early puberty stages but not puberty completion. This may decrease the duration of the pubertal growth spurt and curtail potential catch-up growth that may occur during puberty. Efforts to decrease nutrient deficiencies, stunting and thinness beyond childhood should be made in rural Pakistan.

Self-assessed puberty is reliable in a low-income setting in rural Pakistan.

Objectives Staging sexual maturation is an integral component of adolescent research. The Pubertal Development Scale (PDS) is commonly used as a puberty self-assessment tool because it avoids the use of images. Among the youth living in rural Pakistan, we determined the accuracy of self-reported pubertal assessments using a modified PDS compared to the 'gold standard' of physically assessed Tanner stages by a physician. Methods The strength of agreement between self-assessed puberty using a modified PDS and the 'gold' standard of physician-assessed Tanner stages was reported using weighted kappa (κ w) for girls (n = 723) of 9.0-14.9 years of age or boys (n = 662) of 10.0-15.9 years of age living in the rural District of Matiari. Results Agreement between the gold standard and self-assessment for puberty was substantial, with a κ w of 0.73 (95% confidence interval [CI]: 0.67; 0.79) for girls and a κ w of 0.61 (95% CI: 0.55; 0.66) for boys. Substantial agreement was observed for both boys and girls classified as thinness but only for girls with a normal body mass index. Those who were classified as severely thin had moderate agreement. The prevalence of overestimation was 18.5% (95% CI: 15.9-21.5) for girls and 2.7% (95% CI: 1.7-4.3) for boys, while the prevalence of underestimation estimation was 8.0% (95% CI: 6.2-10.2) for girls and 29.0% (95% CI: 25.8-32.6) for boys. Conclusions Most girls and boys assessed their pubertal development with substantial agreement with physician assessment. Girls were better able to assess their puberty, but they were more likely to overestimate. Agreement for boys was also substantial, but they were more likely to underestimate their pubertal development. In this rural Pakistan population, the PDS seems to be a promising tool for self-assessed puberty.

Nash-wo-Numa (childhood growth & development) study protocol: factors that impact linear growth in children 9 to 15 years of age in Matiari, Pakistan.

INTRODUCTION: Adolescence is a time of significant physical and emotional change, and there is emerging concern that adolescents living in low- and middle-income countries (LMIC) may face substantial challenges in relation to linear growth and mental health. Data on the global burden of stunting after 5 years of age are limited, but estimates suggest up to 50 per cent of all adolescents in some LMIC are stunted. Additionally, many LMIC lack robust mental health care delivery systems. Pakistan has one of the world's largest populations of adolescents (10 to 19 years) at approximately 40 million. The Nash-wo-Numa study's primary objective is to assess the prevalence and risk factors for stunting among early adolescents in rural Pakistan. The study also aims to determine the prevalence of poor mental health and identify factors associated with common mental health concerns during the childhood to adulthood transition. METHODS: This cross-sectional study will include girls (n= 738) 9.0 to 14.9 years of age and boys (n=687) 10.0 to 15.9 years of age who live in the rural district of Matiari, Pakistan. Participants will be assessed for anthropometrical measures, puberty development, nutritional biomarkers as well as symptoms of depression, anxiety and trauma using validated scales. ETHICS AND DISSEMINATION: The proposed study aims to complete the picture of child and adolescent health concerning linear growth and mental health by including puberty indicators. Ethics approval has been granted by the Ethics Review Committee at the Aga Khan University, Karachi, Pakistan, #5251-WCH-ERC-18 and Research Ethics Board at SickKids Hospital, Toronto, Canada, #:1000060684. Study results will be presented at relevant conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03647553; Pre-results.

Effect of life skills building education and micronutrient supplements provided from preconception versus the standard of care on low birth weight births among adolescent and young Pakistani women (15-24 years): a prospective, population-based cluster-randomized trial.

BACKGROUND: Risk factors known to impact maternal and newborn nutrition and health can exist from adolescence. If an undernourished adolescent girl becomes pregnant, her own health and pregnancy are at an increased risk for adverse outcomes. Offering preconception care from adolescence could provide an opportunity for health and nutrition promotion to improve one's own well-being, as well as future pregnancy outcomes and the health of the next generation. METHODS: The Matiari emPowerment and Preconception Supplementation (MaPPS) Trial is a population-based two-arm, cluster-randomized, controlled trial of life skills building education and multiple micronutrient supplementation provided in a programmatic context to evaluate the impact on pre-identified nutrition and health outcomes among adolescent and young women (15-24 years) in Matiari district Pakistan, and the infants born to them within the context of the trial. The primary aim is to assess the effect of the intervention on the prevalence of low birth weight births (< 2500 g). The intervention includes bi-monthly life skills building education provided from preconception, and supplementation with multiple micronutrients during preconception (twice-weekly), pregnancy (daily), and post-partum (daily to 6 months). The standard of care includes non-regulated community-based health sessions and daily iron and folic acid supplementation during pregnancy. Additional outcome information will also be collected at set time periods. Among participants, these relate to nutrition (anthropometry, nutritional status), morbidity, and mortality. Among infants, these include birth outcomes (stillbirth, preterm birth, length of gestation, small for gestational age, birth defects), anthropometry, morbidity, and mortality. DISCUSSION: Preconception care from adolescence that includes interventions targeting life skills development and nutrition is suggested to be important to improving the health and nutrition of adolescent and young women and their future offspring. This study is expected to offer insight into providing such an intervention both within a programmatic context and with an extended exposure period prior to conception. TRIAL REGISTRATION: The MaPPS Trial was registered retrospectively on clinicaltrials.gov (Identifier: NCT03287882 ) on September 19, 2017.

Feasibility and effect of life skills building education and multiple micronutrient supplements versus the standard of care on anemia among non-pregnant adolescent and young Pakistani women (15-24 years): a prospective, population-based cluster-randomized trial.

BACKGROUND: Adolescence is a critical period for physical and psychological growth and development, and vitamin and mineral requirements are correspondingly increased. Health and health behaviours correspond strongly from adolescence to adulthood. Developing a preconception care package for adolescent and young women in resource-limited settings could serve to empower them to make informed decisions about their nutrition, health, and well-being, as well as function as a platform for the delivery of basic nutrition-related interventions to address undernutrition. METHODS: In this population-based two-arm, cluster-randomized, controlled trial of life skills building education (provided bi-monthly) and multiple micronutrient supplementation (provided twice-weekly; UNIMMAP composition), we aim to evaluate the effectiveness of the intervention on the prevention of anemia (hemoglobin concentration < 12 g/dL) among adolescent and young women (15-24 years) in Matiari district, Pakistan compared to the standard of care. Several secondary objectives related to nutrition (anthropometry [height, weight, middle upper arm circumference (MUAC)], nutritional status [iron, vitamin A, vitamin D]); general health (morbidity, mortality); and empowerment (age at marriage, completion of the 10th grade, use of personal hygienic materials during menstruation) will also be assessed. Participants will be enrolled in the study for a maximum of 2 years. DISCUSSION: Empowering adolescent and young women with the appropriate knowledge to make informed and healthy decisions will be key to sustained behavioural change throughout the life-course. Although multiple micronutrient deficiencies are known to exist among adolescent and young women in low-resource settings, recommendations on preconception multiple micronutrient supplementation do not exist at this time. This study is expected to offer insight into providing an intervention that includes both education and supplements to non-pregnant adolescent and young women for a prolonged duration of time within the existing public health programmatic context. TRIAL REGISTRATION: This study is part of the Matiari emPowerment and Preconception Supplementation (MaPPS) Trial. The MaPPS Trial was registered retrospectively on clinicaltrials.gov (Identifier: NCT03287882 ) on September 19, 2017.

Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan.

BACKGROUND: Although the effectiveness of community mobilisation and promotive care delivered by community health workers in reducing perinatal and neonatal mortality is well established, evidence in support of home-based neonatal resuscitation and infection management is mixed. We assessed the effectiveness of adding training in neonatal bag and mask resuscitation and oral antibiotic therapy for suspected neonatal infections to a basic preventive and promotive interventions package delivered by public sector community-based lady health workers (LHWs) in rural Pakistan. METHODS: We did a cluster-randomised controlled trial in two subdistricts of Naushahro Feroze in rural Sindh, Pakistan, between April 15, 2009, and Dec 10, 2012. LHWs, trained in basic newborn resuscitation and in recognition and treatment (with oral amoxicillin) of suspected neonatal respiratory infections, were linked with traditional birth attendants and encouraged to attend home births. Control clusters received routine care through the existing national programme. The primary outcome was all-cause neonatal mortality. Independent data collection teams recorded data for all pregnancies and their outcomes, morbidity, mortality, and household practices related to maternal and newborn care. FINDINGS: Of the 27 randomised clusters with functional LHW programmes, 13 were allocated to the intervention group (n=242 749) and 14 to the control group (n=256 985). In the intervention group, LHWs did 80% of the planned community mobilisation sessions, but were able to attend only 1184 (14%) of 8425 deliveries and 4318 (25%) of 17 288 neonatal visits within 72 h of birth (p<0·0001 for both variables compared with the control group). The neonatal mortality rate was 42 deaths per 1000 livebirths in intervention clusters compared with 55 per 1000 in the control group (risk ratio 0·80, 95% CI 0·68-0·93; p=0·005). INTERPRETATION: The reduction in neonatal mortality in intervention clusters occurred against a background of improvements in domiciliary practices for maternal and newborn care. However, the poor reach of LHWs in accessing newborn infants at birth and in the early postnatal period underscores the limitations of tasking community health workers in public sector programmes working in similar circumstances with such complex interventions. Such community-based interventions in health systems should be accompanied by concerted efforts to improve quality of care in facilities and referral systems. FUNDING: Saving Newborn Lives, Save the Children USA.